Anemia is common after renal transplantation and is frequently undertreated [1-10]. Some studies, for example, have reported incidences of anemia that approach 40 percent at one year posttransplant [2,7,11]. In addition, renal transplant recipients restarting dialysis have lower hemoglobin (Hgb) levels when compared with nontransplant chronic kidney disease (CKD) patients (Hgb levels of 8.9 versus 10.2 g/dL, respectively), which correlate with increased hospitalizations and higher mortality [5]. Use of erythropoiesis-stimulating agents (ESAs) such as epoetin may reduce the frequency and severity of anemia in patients with failing transplants, but have not been shown to reduce mortality [12]. Despite the supposition that renal transplant recipients receive more care from nephrologists, iron status evaluation and appropriate epoetin therapy occur in only 25 percent of transplant patients [3,4]. The reasons for this inadequate care are unclear.

Left ventricular hypertrophy, an important risk factor for cardiovascular mortality among patients with CKD, may be in part a consequence of untreated anemia. Since cardiovascular disease (CVD) is the leading cause of death in diabetic renal transplant recipients, the adverse effects of anemia may be more evident in diabetic renal transplant recipients in the United States, when compared with other nationalities, as the US transplant population has a relatively higher cardiovascular risk profile, with a higher percentage of diabetic patients.

Therefore, treatment of anemia using iron therapy and ESAs has been hypothesized to decrease the cardiovascular morbidity and mortality in renal transplant recipients. However, a study of 825 transplant recipients showed that, in multivariate analyses, anemia was not associated with all-cause mortality, but was associated with 25 percent greater risk of allograft loss [13]. Treatment of anemia does improve quality of life and reduces the requirement for transfusions. (See "Effects of anemia in chronic kidney disease".)

This topic review will address anemia and renal transplant recipients. Anemia associated with CKD in the nontransplant setting, as well as the benefits of the treatment of anemia in the setting of CKD, are also discussed elsewhere. Both topic reviews are relevant since most transplant recipients have an average glomerular filtration rate (GFR) <60 mL/min/1.73 m2, a level consistent with the current definition of CKD. (See "Treatment of anemia in hemodialysis patients" and "Treatment of anemia in nondialysis chronic kidney disease".)

PREVALENCE AND EPIDEMIOLOGY

At the time of transplantation, almost all adult patients can be defined as anemic as target levels for hemoglobin (Hgb) among dialysis patients are only 11 to 12 g/dL. By three months posttransplant, Hgb levels generally rise and then subsequently fall in those with progressive allograft dysfunction. As examples:

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